Adverse events after endoluminal repair of abdominal aortic aneurysms: A comparison during two successive periods of time

Purpose: The aim of this study was to document the incidence rate of adverse events after endoluminal repair of abdominal aortic aneurysms (AAAs) during two successive periods of time. Methods: One hundred ninety patients (175 men, 15 women; mean age, 72 years) underwent endoluminal repair of AAAs in a 5 ½-year period. Adverse events were documented prospectively for all the patients throughout this interval. An adverse event was defined as any of the following events: a death within 30 days, a conversion to open repair, the need for further intervention (either open or endovascular), the need for hemodialysis, a failure to cure the AAA, and wound complications. The patients were divided into two groups—those who underwent operation in the initial 3-year period (group I; n = 75) and those who underwent operation in the subsequent 2 ½-year period (group II; n = 115). The results were analyzed for total adverse events for both periods of time and for difference in incidence rates within categories of adverse events between the two groups. Results: Eight patients (4.2%) died in the perioperative period. The endoluminal repair failed in 17 patients (8.9%), which necessitated a primary conversion to open repair at the original operation. In 88 patients, 110 adverse events occurred. There was no significant difference in the incidence rates of adverse events in patients in group I (37/75) and group II (51/115). Apart from primary conversion (P = .007), there was no significant difference in the incidence rates of adverse events between group I and group II within the following categories: perioperative (within 30 days) deaths, primary conversion, secondary conversion, supplementary endoluminal repair, intervention for lower limb ischemia, hemodialysis necessitated, failure to cure the AAA as a result of persistent endoleak, and wound complications. Conclusion: Despite improvements in technology and increasing experience, adverse events continue to occur in a relatively high proportion of patients (45%) who undergo endoluminal repair of AAA. Reporting the incidence rates of adverse events provides a more accurate picture of the morbidity rates of the endoluminal method rather than simply listing the procedures as successes or failures. The similarity in the incidence rates of adverse events in patients in group I and group II suggests that there are inherent risks in the endoluminal method rather than iatrogenic complications that occur during the learning curve with a new technique. (J Vasc Surg 1999;29:32-9.)     

Abdominal aortic aneurysm repair in Veterans Affairs medical centers

Purpose: This study was performed to define outcomes after abdominal ortic aneurysm (AAA) repair in Veterans Affairs (VA) medical centers during fiscal years 1991 through 1993.Methods: With VA patient treatment file data, patients were selected from diagnosis-related groups 110 and 111 and were then classified in a patient management category. In the categories of repair of nonruptured and ruptured AAA, mortality and postoperative complication rates were defined for patients who underwent AAA repair in VA medical centers during the 3-year study period.Results: Hospital mortality rates were 4.86% (166 of 3419) after repair of nonruptured AAA and 47.0% (126 of 268) after repair of ruptured AAA ( p < 0.001). Of 292 deaths after AAA repair, 126 (43.2%) followed repair of ruptured AAA, even though ruptured AAA comprised only 7.3% of total AAA surgical volume. AAA repairs were performed at 116 VA medical centers, with 31.8 ± 23.1 (range, 1 to 140) procedures performed at each center. Although many lower-volume centers had excellent results, centers that performed ≥32 AAA repairs tended to have lower in-hospital mortality rates after repair of nonruptured AAA than those that performed ≤31 procedures (4.2% ± 3.5% compared with 6.7% ± 7.8%; p < 0.05). Poisson regression analysis revealed an inverse relationship between the volume of AAA repairs and individual hospital mortality ( p = 0.001) and a direct relationship between illness severity and hospital mortality ( p = 0.008). The proportion of ruptured AAAs treated in a hospital was also directly related to individual hospital mortality rates ( p < 0.005). Postoperative complications were associated with an increased hospital mortality rate (11.7% with complication compared with 6.5% without; p < 0.001) and length of stay (23.6 ± 17.1 days compared with 18.0 ± 12.4 days; p < 0.0001). In a logistic regression model, increased mortality rates after AAA repair were associated with hospital type (adjusted odds ratio [OR] = 0.6), increasing age (OR = 1.1), patient management category severity score (OR = 2.2), hemorrhage (OR = 2.3), myocardial infarction (OR = 2.6), disseminated intravascular coagulation (OR = 4.7), AAA rupture (OR = 6.0), postoperative shock (OR = 10.7), cardiopulmonary arrest (OR = 15.4), central nervous system complications (OR = 16.0) and urologic complications (OR = 2.4).Conclusions: Mortality rates after AAA repair in VA hospitals were comparable with those previously reported in other large series. Outcomes for veterans with AAA may improve by referring patients eligible for elective repair to VA medical centers with a greater operative volume or to lower-volume centers that have had excellent results. (J VASC SURG 1996;23:191-200.)     

Ruptured versus Elective Abdominal Aortic Aneurysm Repair: Outcome and Cost

During a recent 30-month period, we repaired 10 ruptured abdominal aortic aneurysms (RAAA) at our institution. To evaluate the survival, postoperative morbidity, and financial impact of treating RAAA, we compared these patients with 10 randomly selected patients undergoing elective AAA (EAAA). Both groups were comparable for age, gender, and incidence of diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease (COPD), and renal failure. Although we have noted a dramatic increase in survival for RAAA (90%), the morbidity continues to be unacceptably high (60%). Efforts should be made toward better detection of AAA prior to rupture as well as development of strategies to minimize or prevent these major complications. Potential average savings accrued from one patient undergoing EAAA repair rather than RAAA repair ($93,139. 21) can be used to perform screening abdominal ultrasound tests in patients at increased risk of having an AAA.     

TREATMENT OF ABDOMINAL AORTIC ANEURYSM DISEASE IN THE 9TH AND 10TH DECADES OF LIFE

Background : The appropriate management of patients who are older than 80 years of age and who present with an abdominal aortic aneurysm (AAA) remains controversial. While it appears that elective repair can be performed safely, appropriate management of these patients in the emergency situation is unclear. The purpose of the present study was to examine the results obtained in treating this elderly group in the elective and emergency setting, by operation and conservative techniques at St George Hospital, Kogarah. Methods : Between January 1987 and December 1994 85 patients older than 80 years of age were treated for AAA. These patients were divided into four groups: I, elective presentatiodno surgery; II, elective presentatiodelective surgical repair; III, emergency presentatiodsurgical repair; and IV, emergency presentatiodconservative treatment. We examined age, sex, size of AAA, mode of presentation, type of treatment, length of survival and cause of death. Results : The mean age of the total group (n = 85) of patients was 84 years (range: 80–94). The mean AAA diameter for this group was 5.6 cm (95% CI: 5.2–6 cm). The diameters for group I (n= 40), II (n= 22), III (n= 16) and IV (n = 7) were 4.9 cm (4.4–5.5, 95% CI), 5.7 (4.9–6.5 CI), 7.0 (6.1–7.7 CI) and 6.2 (5.2–7.2 CI), respectively. The median survival for groups I, II, III and IV was 18, 38.5, 0.25 and 0 months, respectively. Group II had a longer survival than any other group (P= 0.015). and group IV had a shorter survival than the total group (P= 0,001). However, the length of survival was no different for III versus IV (P= 0.146). Deaths in each group were due to the following reasons. I: cardiopulmonary events (14), rupture (3), malignancy/sepsis (3); II: cardiopulmonary events (3), rupture (thoracic aneurysm) (2). malignancy (1); III: rupture (10), malignancy (1); and (IV): rupture (6), malignancy (1). Conclusions : Elective surgical repair offers the best management option for AAA in patients older than 80 years of age. Death may still occur from progression of aneurysmal disease at other sites. An aggressive surgical approach to the management of haemodynamically unstable patients in this age group is of questionable benefit.     

Endovaskuläre AAA-Therapie

Purpose. We analyzed the clinical efficacy of endovascular AAA repair in midterm follow-up and scrutinized the causes of graft-dependent endoleaks (type I EL). For this purpose, we investigated whether a restrictive patient selection can reduce the incidence of type I EL. Patients and results. A consecutive series of 83 patients who underwent elective endovascular AAA repair during 4/1995 and 9/1999 was analyzed. Mean follow-up was 12 months. Twenty tube grafts and 63 bifurcated grafts were used. With the help of a risk score classifying preoperative AAA morphologies into three risk groups, morphological AAA difficulties and clinical outcomes were set in reference and morphological alterations of the crucial fixation sites were amassed. Perioperative mortality was 1 of 83 (1.2%) and primary technical success 80 of 83 (96.4%). We observed one rupture 36 months postoperatively that responded to endovascular treatment. Conversion was 6 of 83 (7.2%). Type I EL occurred in 13 of 83 patients (15.7%). Of 13 type I EL patients, 9 (69.2%) responded to secondary endovascular treatment, while 4 of 13 patients (30.8%) had to be converted due to type I EL. While 70 of 83 patients (84.3%) without type I EL showed a significant decrease of maximum AAA diameter (D_max) 12 months postoperatively, D_max did not show shrinkage in 13 of 83 patients (15.7%) with type I EL (p=0.0035). In 4 of 20 patients (20%) treated with tube grafts, type I EL occurred besides a significant dilatation of the distal aortic neck 12 months postoperatively, whereas in 16 of 20 patients (80%) treated with tube grafts, neither type I EL nor a significant dilatation of the distal aortic neck was observed (p=0.0354). Of 63 patients treated with bifurcated devices, 9 (14.3%) showed type I EL and a significant dilatation of iliac artery diameters 18 months postoperatively, while 54 of 63 patients (85.7%) without type I EL did not show a significant expansion (left common iliac artery p=0.0269, right common iliac artery p=0.0071). We found a significant relationship between preoperative AAA morphologies with a higher risk score and the occurrence of type I endoleaks (p=0.022). Conclusions. The causes of the complications in the cohort observed were morphological alterations of the aortoiliac vessels, technical difficulties regarding the exact fitting of endovascular grafts, or a combination of these problems. Restrictive morphological patient selection, precise preoperative imaging, and differentiated graft choice as well as correct fitting of the graft will have the potential to decrease the incidence of type I endoleaks in the future.     

Initial experience with endovascular aneurysm repair: Comparison of early results with outcome of conventional open repair

Purpose: To determine the safety, effectiveness, and problems encountered with endovascular repair of abdominal aortic aneurysm (AAA). Initial experience with endoluminal stent grafts was examined and compared with outcome for a matched concurrent control group undergoing conventional operative repair of AAA. Methods: Over a 3-year period, 30 patients underwent attempts at endovascular repair of infrarenal AAA. Of the 28 (93%) successfully implanted endografts, 8 were tube endografts, 8 bifurcated grafts, and 12 aortouniiliac grafts combined with femorofemoral bypass. Most of the procedures were performed in the past year because the availability of bifurcated and aortoiliac endografts markedly expanded the percentage of patients with AAA who might be treated with endoluminal methods. The follow-up period ranged from 1 to 44 months, with a mean value of 11 months. Results: Endovascular procedures demonstrated significant advantages with respect to reduced blood loss (408 versus 1287 ml), use of an intensive care unit (0.1 versus 1.75 days), length of hospitalization (3.9 versus 10.3 days), and quicker recovery (11 versus 47 days). Although the total number of postoperative complications was identical for the two groups, the nature of the complications differed considerably. Local and vascular complications characteristic of endovascular repair could frequently be corrected at the time of the procedure and tended to be less severe than systemic or remote complications, which predominated among the open surgical repair group. On an intent-to-treat basis, 23 (77%) of the 30 AAAs were successfully managed with endoluminal repair. The seven (23%) failures were attributable to two immediate conversions caused by access problems, three persistent endoleaks, one late conversion caused by AAA expansion, and one late rupture. Conclusions: Although less definitive than those for conventional operations, these early results suggest that endovascular AAA repair offers considerable benefits for appropriate patients. The results justify continued application of this method of AAA repair, particularly in the treatment of older persons at high risk. (J Vasc Surg 1998;27:992-1005.)     

Cerebrospinal fluid drainage and distal aortic perfusion: Reducing neurologic complications in repair of thoracoabdominal aortic aneurysm types I and II

Purpose: This study was conducted to evaluate the role of cerebrospinal fluid (CSF) drainage and distal aortic perfusion (DAP) in the prevention of postoperative neurologic complications for high-risk patients who had undergone type I and type II thoracoabdominal aortic aneurysm (TAAA) repair.Methods: CSF drainage and DAP were used as an adjunct in the treatment of 94 patients with TAAA (31 type I, 63 type II) between September 1992 and December 1994; 67 were men and 27 were women. The median age was 64 years (range, 28 to 88 years). Aortic dissection occurred in 35 of 94 patients (37%). Thirty-six of 94 patients (38%) had previously undergone proximal aortic surgery. All patients underwent intraoperative DAP and perioperative CSF drainage. Median aortic cross-clamp time was 67 minutes (range, 20 to 131 minutes).Results: The 30-day survival rate was 90% (85 of 94 patients). Early neurologic complications occurred in 5 of 94 patients (5%), and late neurologic complications occurred in 3 of 94 patients (3%). We compared the neurologic complications of our current group of 94 patients with the data from 42 patients (control group) who also underwent repair of TAAA type I and type II with only simple cross-clamp and without CSF drainage or DAP. Both groups were treated by the senior author (HJS) at the same institution. Total neurologic complications for the current group occurred in 8 of 94 patients (9%) versus 8 of 42 patients (19%) for the control group ( p = 0.090). Neurologic complications for patients with type II TAAA occurred in 8 of 63 patients (13%) versus 17 of 42 patients (41%) ( p = 0.014). For all patients with aortic clamp times ≥45 minutes, neurologic complications occurred in 7 of 55 (13%) versus 7 of 18 (39%) ( p = 0.033).Conclusion: The period of risk during aortic cross-clamp time is reduced with the adjuncts of CSF drainage and DAP, which significantly lower the incidence of neurologic complications after repair of TAAA types I and II. (J VASC SURG 1996;23:223-9.)     

Ruptured abdominal aortic aneurysm: Six-year follow-up results of a multicenter prospective study

Purpose: On the basis of a prospective analysis of 147 patients undergoing surgery for ruptured abdominal aortic aneurysm (AAA) and recorded in the Canadian Society for Vascular Surgery Aneurysm Registry, this study defines the early and 6-year actuarial survival rates and determines the predictive variables that are associated with survival.Methods: Ongoing follow-up of a cohort of patients was current at the time of analysis. To identify the preoperative, intraoperative, and postoperative variables that were associated with survival, statistical methods included chi-squared analysis, logistic regression analysis, Kaplan-Meier analysis, and Cox regression analysis.Results: The survival rate was 48.6% at 1 month, 34.7% ± 4.2% at 3 years, and 22.0% ± 4.0% at 6 years. When preoperative and intraoperative variables were considered and logistic regression analysis was used, the highest probability of early in-hospital survival was associated with preoperative creatinine levels of 1.3 mg/dl or less, intraoperative urine output of 200 ml or greater, and infrarenal clamp site. The highest probability of late survival, as calculated by the Cox proportional hazards method, was predicted by the patient's age and total urine output during the procedure. When all variables, including postoperative complications, were considered, late survival was highest if intraoperative urine output was 200 ml or greater and respiratory failure and myocardial infarction did not occur. For those patients with ruptured AAA who survived operation (i.e., greater than 1 month), the long-term survival rate was significantly lower than a comparable group undergoing repair of nonruptured AAA.Conclusions: Patients who survive repair of a ruptured AAA have a lower late survival rate than patients undergoing elective repair. When a patient is evaluated before operation, no combination of preoperative variables could identify those patients with little or no chance of survival; hence, the decision to repair a ruptured AAA should be made on clinical grounds. However, after surgery (when information on intraoperative and postoperative variables is also available), the results of this study provide a basis for the surgeon to use these prognostic variables to assist clinical judgment and guide discussions on prognosis with the family and to identify those patients who have such a low chance of early and late survival that further aggressive treatment may be futile. (J VASC SURG 1994;19:888-900.)     

Mortality,Morbidity, and Costs of Ruptured and Elective Abdominal Aortic Aneurysm Repairs in Nova Scotia,Canada

Ruptured abdominal aortic aneurysms (RAAA) have a 78-94% mortality rate. If cost-effectiveness of screening programs for abdominal aortic aneurysms (AAA) are to be assessed, direct costs for RAAA repairs and elective AAA (EAAA) repairs are required. This study reports mortality, morbidity, and direct costs for RAAA and EAAA repairs in Nova Scotia in 1997-1998 and also compares Nova Scotia and U.S. costs. We performed a retrospective study of 41 consecutive RAAA and 48 randomly selected EAAA patients. Average total costs for RAAA repair were significantly greater than those for EAAA repair (direct costs: $15,854 vs. $9673; direct plus overhead costs: $18,899 vs. $12,324 [pricing in 1998 Canadian dollars]). Intensive care unit length of stay and blood product usage were the most substantial direct cost differentials ($3593 and $2106). Direct cost for preoperative testing and surveillance was greater in the EAAA group ($839 vs. $33). Estimates of U.S. in-hospital RAAA and EAAA repair costs are more than 1.5 times Nova Scotia costs. Direct in-hospital RAAA repair costs are $6181 more than EAAA repair costs. These in-hospital cost data are key cost elements required to assess the cost-effectiveness of various screening strategies for earlier detection and monitoring of AAA within high-risk populations in Canada. Further studies are required to estimate cost per quality-adjusted-life-year gained for various AAA screening and monitoring strategies in Canada.     

Late survival after elective repair of aortic aneurysms detected by screening.

BACKGROUND: The aim of this study was to examine whether there was any survival advantage in men following elective repair of an abdominal aortic aneurysm (AAA) detected by ultrasound screening compared to those with an AAA detected incidentally. METHODS: A total of 424 men underwent elective AAA repair between 1990 and 1998; 181 were detected in an aneurysm screening programme and 243 were diagnosed incidentally. Follow-up survival data were collected until 2003 (minimum 5 years) and survival curves were compared using regression analysis. RESULTS: The postoperative 30-day mortality rate was significantly lower in men whose aneurysms were detected by screening (4.4%), compared with those detected incidentally (9.0%). Similarly, 5-year survival (78% vs. 65%) and 10-year survival rates (63% vs. 40%) were better after repair of a screen-detected AAA (p<0.0003 at all time intervals, by log rank testing). Multivariate analysis showed that this was largely due to the older age of men who had repair of an incidental AAA (71.2 vs. 67.1 years). CONCLUSION: Men who had elective repair of an AAA detected by screening had a better late survival rate than men whose aneurysm was discovered incidentally because they were younger at the time of surgery.     

Historic control comparison of outcome for matched groups of patients undergoing endoluminal versus open repair of abdominal aortic aneurysms

Purpose: Currently no randomized studies show the relative morbidity and mortality of the open and endoluminal methods of abdominal aortic aneurysm (AAA) repair. The aim of this study was to analyze the outcome of two matched groups of patients with AAA, one undergoing open repair and the other undergoing endoluminal repair.Methods: Two groups of patients who had undergone repair of AAA by open technique (group 1) or by endoluminal methods (group 2) were compared. A historic control cohort of 27 patients was selected from 56 consecutive patients who underwent open repair of AAA between January 1991 and February 1992. Patients considered unsuitable for the endoluminal method on the basis of computed tomography and aortography were excluded (n = 29). Between May 1992 and November 1994 prospective data were recorded for 62 consecutive patients who underwent endoluminal repair by tube or bifurcated endografts. Twenty-eight patients who had been specifically referred for endoluminal AAA repairs because of preexisting severe medical comorbidities were excluded. Six of the endoluminal cases had failure, requiring conversion to open operation, and were excluded for separate analysis, leaving 28 patients in group 2. Patients in both groups were thus fit and suitable for either open or endoluminal repair and were comparable in relation to age, sex, risk factors, dimensions, and form of AAA.Results: The mean values for operation time, blood loss, intensive care stay, and hospital stay for group 1 and group 2 were 2.6 versus 3.1 hours, 1422 versus 873 ml,* 1.8 versus 0.7 days,* and 12.4 versus 11.1 days, respectively (*p < 0.05). Local/vascular complications occurred in 15% of patients in group 1 compared with 25% in group 2 (p = 0.55), whereas remote/systemic complications occurred in 37% and 29%, respectively (p = 0.3). Five of 28 patients in the endoluminal group had complications requiring early operative repair (n = 3) or late revision (n = 2). When comparison was made on an intention-to-treat basis (with failed procedures included), the incidence of local/vascular complications was significantly greater for endoluminal repair (p = 0.047).Conclusions: The incidence of systemic/remote complications was similar for the two groups in spite of significantly less blood loss and shorter intensive care unit stay with endoluminal repair. The incidence of local/vascular complications had a tendency to be higher for endoluminal compared with standard open method (and was significantly greater if failed procedures were included). In this early experience with prototype devices, patients who were medically suitable for open surgical procedures did not derive benefit from the less invasive endoluminal technique with respect to duration of operation, length of hospital stay, or perioperative morbidity and mortality. On the other hand, because they also did not have worse outcome, a randomized study is now justified in this group. (J VASC SURG 1996;23:201-12.)     

Influence of sex on the results of abdominal aortic aneurysm repair

Purpose: The purpose of this study is to determine the effect of sex on the survival rate and complications after repair of nonruptured and ruptured abdominal aortic aneurysms (AAA).Methods: The Canadian Society for Vascular Surgery Aneurysm Registry formed the database for analysis and provided current, ongoing follow-up of the patients. Statistical methods included t tests, chi-squared analysis, Kaplan-Meier analysis, and Cox regression analysis.Results: Of the 679 patients undergoing repair of a nonruptured AAA, 19.7% were women and 82.3% men. The following risk factors were significantly different (p < 0.05) in women and men: women were older; more had never smoked; more had a positive family history of AAA; fewer had an electrocardiogram showing evidence of an old myocardial infarction; more had coexisting aortoiliac occlusive disease; fewer had popliteal or femoral aneurysms; and the average size of the AAA was smaller. In spite of potential differences in risk, the in-hospital mortality rates were not affected by sex: 5.2% mortality rate for women and 4.4% for men. Early and late vascular complications occurred with a similar prevalence. The late survival rates were not different in women and men: for women, the 1-, 3-, and 5-year cumulative survival rates were 93.0%, 74.2%, and 63.3%, respectively, and for men 90.3%, 82.8%, and 68.9%. To control for the potential effects of other confounding variables on survival, the Cox proportional hazards method was used. When sex was included in a model along with other significant predictive variables of late survival, sex was not found to be a significant predictor of late results. Of the 146 patients with a ruptured AAA, 13.7% were women and 83.3% men. The in-hospital mortality rates were not significantly different: 55.0% for women and 49.2% for men. There was no difference between the cumulative survival rates: the 3- and 5-year survival rates for women were 36.0% and 9.0%, respectively, and for men 33.9% and 26.9%.Conclusions: Sex was not found to have an effect on the early or late results after repair of nonruptured or ruptured AAA. However, a literature review suggests the possibility of a gender bias in the diagnosis and/or selection of patients for surgical treatment because the proportion of women in surgical series is generally less than the proportion determined from autopsy studies, ultrasound studies, hospital discharge data, and national mortality information. (J VASC SURG 1994;20:914-26.)     

Long-term coronary artery outcome after arterial switch operation for transposition of the great arteries

Objective: To analyse the long-term patency of coronary arteries after neonatal arterial switch operation (ASO). Methods: A retrospective study of the operative reports, follow-up and postoperative catheterisation data of 119 patients, who underwent the great arteries (TGA) repair since 1991, has been carried out. Patient population: Among the 133 survivors of the 137 ASOs performed between 1991 and 2007, 119 patients have been studied by routine control cardiac catheterisation and form the study population. Median time between repair and the coronary angiography was 2.9 ± 1.9 years. A comparison between the eight patients (6.7% out of the entire study population), known to have postoperative coronary obstructions (group I) and the rest of the cohort with angiographic normal coronary vessels (group II) was performed by univariate analysis of variance and logistic regression models. One patient had surgical plasty of the left coronary main stem with subsequent percutaneous angioplasty, three patients had primary coronary stent implantation and four patients had no further intervention at all. In group I, all but one patient denied symptoms of chest pain and echocardiography failed to show any difference between the two groups in terms of left ventricular systolic function (ejection fraction group I 61 ± 2% vs 62 ± 6% of group II, p = 1.0). Results: The association of coronary obstruction with complex native coronary anatomy (Yacoub type B to E) was evident at both univariate (62% of group I vs 22% of group II, p = 0.04) and logistic regression (p = 0.007, odds ratio (OR) 8.1) models. The type of coronary reimplantation (i.e., coronary buttons on punch vs trap-door techniques) was similar between the two groups (punch reimplantation in 25% of patients of group I vs 31% of group II, p = 0.1) as was the relative position of the great vessels (aorta anterior in 100% of patients of group I vs 96% of group II; univariate, p = 0.1). Conclusions: The late outcome in terms of survival and functional status after ASO is excellent. Nevertheless, the risk of a clinically silent late coronary artery obstruction of the reimplanted coronary arteries warrants a prolonged follow-up protocol involving invasive angiographic assessment.     

Emergency surgery of non-ruptured abdominal aortic aneurysm

BACKGROUND AND AIMS: The pain of an abdominal aortic aneurysm (AAA) is believed to signify rupture, and emergency surgery for symptomatic AAA is a widely accepted practice to prevent rupture. To clarify the benefit of emergency surgery we evaluated the clinical course of emergency treated patients with non-ruptured AAAs. MATERIAL AND METHODS: 110 patients (90 men, mean age 69, range 49-93; 20 women, mean age 75, range 63-89) underwent emergency repair of non-ruptured AAA between 1970 and 1992 at the Department of Thoracic and Cardiovascular Surgery of Helsinki University Central Hospital (HUCH). Survival rates after surgery were analysed using product-limit-survivorship method. The survival rates after age-stratification were compared with those of patients undergone elective surgery (n=599) or emergency surgery because of ruptured AAAs (n=363) during the same period. Risk factors affecting early and late survival rates after operation were analysed by logistic regression analysis and Cox proportional hazard model. RESULTS: Thirty-day operative mortality rates were 18 % (20/110) in the emergency non-ruptured group, compared with 7 % (42/599) in the elective group and 49 % (179/363) in the ruptured group (p<0.05). Thirty day survival rate was not changed among the nonruptured emergency group from 1970 to 1992, whereas the rates of ruptured and elective groups became better during the study period. Late survival rates for 30-day postoperative survivors were clearly reduced among the non-ruptured emergency group, without difference between the emergency operated ruptured and non-ruptured groups. Coronary artery disease was decreasing significantly early and late survival rates after emergency surgery for non-ruptured AAAs (p<0.05, logistic regression and p<0.001 Cox proportional hazard). CONCLUSIONS: Early and late mortality risk is significantly higher (p<0.001) after emergency surgery for haemodynamically stable non-ruptured AAA than after elective surgery, mainly because of coronary artery disease.     

The incidence of hypomagnesaemia following abdominal aortic aneurysm surgery

IntroductionMagnesium is important for cardiac function. Hypomagnesaemia is associated with a higher incidence of arrhythmias and poorer outcomes in cardiac surgery. No studies have investigated the incidence or impact of postoperative hypomagnesaemia after abdominal aortic aneurysm (AAA) surgery. We aim to assess the incidence of hypomagnesaemia after AAA repair in our population.MethodsRetrospective analysis was performed of patients who underwent elective AAA surgery at a single vascular centre. The last 110 patients undergoing open or endovascular AAA repair were identified. The hospital pathology system was used to identify the immediate postoperative serum magnesium levels as well as patient demographics and admission details. Hypomagnesaemia was defined as serum magnesium of <0.7mmol/l.ResultsA total of 211 patients were studied and there were 3 deaths. Of the patients included, 101 underwent open elective AAA repair and 110 underwent endovascular repair. In the elective open repair group, 73 patients (73%) were hypomagnesaemic. In the endovascular repair group, 35 (32%) had hypomagnesaemia. A t-test showed a statistically significant difference in hypomagnesaemia between the open and endovascular groups (p<0.001).ConclusionsAAA surgery is associated with a high incidence of postoperative hypomagnesaemia, which is significantly greater among open repair patients. This is likely to have an effect on cardiac activity and lead to cardiac complications such as arrhythmias and poorer postoperative outcomes, especially in the open AAA repair subgroup. This stresses the importance of serum magnesium and cardiac monitoring in the postoperative phase. A prospective study is proposed to further investigate these findings, and their potential implications on perioperative morbidity and mortality.     

Rupture of abdominal aortic aneurysm (RAAA)--predictors of the early postoperative mortality

PURPOSE: To evaluate the main factors of the 30 days mortality rate of patients operated on for abdominal aortic aneurysm rupture (RAAA. PATIENTS AND METHOD: Univariate and multivariate analysis of various factors associated with RAAA was performed in a group of 73 patients operated on for RAAA between 1996-2001. RESULTS: The 30 days mortality rate was 35.6 %. The main factors of mortality were: misdiagnosis, cardio- pulmonary-cerebral resuscitation (CPCR) on admission, configuration of RAAA, number of blood transfusions, hypotension on admission (p < 0.0001) and duration of operation, type of reconstruction and hypertension in anamnesis (p < 0.01). Important factors (p < 0.05) of postoperative mortality were also low haemoglobin level on admission, abdominal aortic aneurysm (AAA) diameter and ischaemic heart disease in anamnesis. The probability of patient's death is the highest (p < 0.003), if factors like CPCR, number of blood transfusions and aneurysm diameter are combined (multivariate analysis, stepwise method). CONCLUSION: The early detection and surgical or endovascular elective treatment of AAA, the regular dispensation of patients with small AAA especially in hypertonics, the correct diagnosis of RAAA without time delay are the best tools for patients survival. The patient's chance for survival increases with highly trained prehospital resuscitation system and experienced team of vascular surgeons and anesthesiologists.     

Improved outcomes in the treatment of gastroschisis using a preformed silo and delayed repair approach

Background/Purpose: The aim of this study was to critically evaluate the clinical outcomes of two different surgical treatment approaches for infants born with gastroschisis. Methods: The medical records of 65 infants with gastroschisis treated at one institution from 1991 to 2000 were available. Infants in group I (prior to December 1998) underwent attempted early repair of the gastroschisis defect on their first day of life. Infants in group II had delayed repair after the initial placement of a preformed silo. Results: Group I had 39 patients; group II had 26 patients. The two groups were equal with respect to maternal age, gestational age, and birth weight. Complete reduction and fascial closure were accomplished for 32 patients (82%) in group I and 25 patients (96%) in group II (P [lt ] .02). Median time on the ventilator was significantly less for group II (P [lt ] .0001). Infants in group II had shorter times until first postoperative feeding (P [lt ] .01) and full feedings (P [lt ] .006). Group II had fewer complications than group I (23% v 56%; P [lt ] .01). There appeared to be less necrotizing enterocolitis in group II. The average length of hospital stay was 14 days less for group II. Conclusions: The use of a preformed silo initially followed by delayed fascial closure in infants with gastroschisis is associated with improved fascial closure rates, fewer ventilator days, more rapid return of bowel function, and fewer complications compared with attempts at initial early repair. J Pediatr Surg 38:459-464.     

Role of Pre-operative Multiple Gated Acquisition Scanning in Predicting Long-Term Outcome in Patients Undergoing Elective Abdominal Aortic Aneurysm Repair

Objective

To determine whether resting pre-operative left ventricular ejection fraction (LVEF) estimated by multiple gated acquisition scanning (MUGA) predicts long-term survival in patients undergoing elective abdominal aortic aneurysm (AAA) repair.

Methods

A retrospective study of MUGA scans which were performed to estimate pre-operative resting LVEF in 127 patients [106 (83 %) males, mean age 74 ± 7.6 years] who underwent elective AAA repair over a period of 4 years from March 2007. We compared outcomes and long-term survival between patients who had a pre-operative LVEF ≤ 40 % (Group 1, n = 60) and LVEF > 40 % (Group 2, n = 67).

Results

Overall 19 (15 %) patients died during the follow-up period (13 patients in group 1 and 6 patients in group 2). 30-day mortality was 8 %. There was no significant difference between group 1 and 2 in terms of patients’ mean age or median length of hospital stay (8 days for both groups, p = 0.61). However, group 2 had more females than group 1(18 vs. 3, p = 0.001). Median survival for patients in group 2 was significantly higher than patients in group 1 (1,258 days vs. 1,000 days, p = 0.03). In a Cox regression model which included age, sex, smoking status and LVEF as covariates, only smoking status and LVEF predicted survival [Hazard ratio (HR) = 1.06, p = 0.04 and HR = 0.93, p = 0.00, respectively].

Conclusion

This study shows that there is a role for pre-operative MUGA scan assessment of resting LVEF in predicting long-term survival post elective AAA repair and that the lower the pre-operative LVEF the poorer the long-term outcome.     

A randomized trial of intraoperative autotransfusion during aortic surgery

Purpose: The net benefit of routine intraoperative autotransfusion (IAT) in patients undergoing elective infrarenal aortic surgery was studied. Methods: One hundred patients undergoing abdominal aortic aneurysm (AAA) repair (n = 50) or aortofemoral bypass (AFB) for occlusive disease (n = 50) were randomized to IAT and control groups. This experience accounted for 58% of patients undergoing aortic surgery during the 16-month study period. Results: IAT and control groups were balanced for preoperative demographics, disease (50:50 split of AFB:AAA in each group), and risk factors. There were no significant differences between patients randomized to IAT and control patients in estimated blood loss (EBL), allogeneic blood transfusion (units administered intraoperatively, postoperatively, and total), proportion of patients not receiving allogeneic blood (34% of patients randomized to IAT and 28% of control patients), postoperative hemoglobin/hematocrit levels, and complications. IAT did not reduce allogeneic blood transfusion among all patients undergoing aortic surgery nor in any subgroups that might be more likely to benefit, such as those undergoing AAA repair, those with 1000 mL or more EBL, and those receiving larger volumes of IAT-processed blood. Conclusion: We could find no net benefit of IAT in patients undergoing elective, infrarenal aortic surgery. (J Vasc Surg 1999;29:22-31.)     

Is preoperative cardiac evaluation for abdominal aortic aneurysm repair necessary?

Purpose: It is reported that 25% to 50% of patients with abdominal aortic aneurysms (AAA) have severe coronary artery disease (CAD) and should undergo an aggressive cardiac workup before AAA repair. In contrast, it has been our policy that patients referred for AAA repairs undergo no cardiac testing before surgery.Methods: This report reviews the last 113 consecutive patients who underwent elective AAA repair by the senior author using this policy. Seventy-four patients (group A) had only an electrocardiogram before surgery. The remaining 39 patients (group B) were referred having already had additional testing that included a thallium stress test (n = 20), echocardiogram (n = 18), multiple gated acquisition (MUGA) scan (n = 3), cardiac catheterization (n = 8), or some combination of these.Results: There was no statistical difference between group A and group B with regard to age, sex, tobacco use or history of coronary artery disease, diabetes mellitus, stroke (CVA), hypertension, peripheral vascular disease, or chronic obstructive pulmonary disease. Group B more commonly had a history of myocardial infarction (41% vs 19%, p < 0.03) and congestive heart failure (23% vs 7%, p < 0.03). During surgery there was no significant differences in blood loss, transfusion requirements, or operative times. There were no myocardial infarctions in group A and two (5.1%) in group B, which was not significantly different. Other complications, such as CVA, renal failure, pulmonary failure, pneumonia, wound infection, and hemorrhage, were not significantly different between the two groups. Postoperative hospital stay was not significantly different. There were three deaths in the entire series (2.7%), and only one in group B was cardiac-related in a patient with known end-stage cardiac disease and a symptomatic 8 cm AAA.Conclusions: These data indicate that most patients with AAA can safely undergo repair with no cardiac workup and that cardiac workup before AAA repair contributes little information that impacts on treatment or final clinical outcome. We conclude that cardiac testing in preparation for AAA repair is not usually necessary and that intraoperative hemodynamic management may be the most important variable in determining outcome. (J Vasc Surg 1997;25:152-6.)